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Use of Acellular Dermal Matrix in Postmastectomy Breast Reconstruction: Are All Acellular Dermal Matrices Created Equal? Plast Reconstr Surg 2015; 136:647-653. [PMID: 26397242 DOI: 10.1097/prs.0000000000001569] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND AlloDerm and FlexHD are two types of acellular dermal matrices commonly used in implant-based reconstruction. Although the use of acellular dermal matrix has revolutionized immediate breast reconstruction in the setting of breast cancer, it remains unclear which type of acellular dermal matrix is best. The purpose of this retrospective cohort study was to compare postoperative complication rates between these two types of acellular dermal matrix. METHODS The authors reviewed the records of all patients who underwent implant-based breast reconstruction at their institution between 1998 and 2013. Dependent variables of seroma, hematoma, infection, delayed wound healing, implant exposure, and return to the operating room for management of complications were recorded. RESULTS A total of 309 consecutive patients were identified. Of these, AlloDerm was used in 123 patients (39.8 percent) and FlexHD was used in 186 patients (60.2 percent). Most patients in the authors' cohort underwent immediate reconstruction [n = 288 (93.2 percent)], with a mean follow-up of 20.0 months. Patients receiving AlloDerm were half as likely to have major infections compared with patients receiving FlexHD (OR, 0.50; 95 percent CI, 0.16 to 1.00; p < 0.05). The rates of other complications were similar between the two groups. CONCLUSION There are significantly increased odds of a major infection in patients who undergo implant-based breast reconstruction using FlexHD compared with AlloDerm. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, III.
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Tolérance du lambeau de grand dorsal sans prothèse à la radiothérapie en reconstruction mammaire immédiate. ANN CHIR PLAST ESTH 2015; 60:500-5. [DOI: 10.1016/j.anplas.2015.05.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2014] [Accepted: 05/20/2015] [Indexed: 11/20/2022]
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Mastectomy Weight and Tissue Expander Volume Predict Necrosis and Increased Costs Associated with Breast Reconstruction. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2015; 3:e450. [PMID: 26301139 PMCID: PMC4527624 DOI: 10.1097/gox.0000000000000408] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2014] [Accepted: 05/04/2015] [Indexed: 12/26/2022]
Abstract
Introduction: Impaired vascular perfusion in tissue expander (TE) breast reconstruction leads to mastectomy skin necrosis. We investigated factors and costs associated with skin necrosis in postmastectomy breast reconstruction. Methods: Retrospective review of 169 women with immediate TE placement following mastectomy between May 1, 2009 and May 31, 2013 was performed. Patient demographics, comorbidities, intraoperative, and postoperative outcomes were collected. Logistic regression analysis on individual variables was performed to determine the effects of tissue expander fill volume and mastectomy specimen weight on skin necrosis. Billing data was obtained to determine the financial burden associated with necrosis. Results: This study included 253 breast reconstructions with immediate TE placement from 169 women. Skin necrosis occurred in 20 flaps for 15 patients (8.9%). Patients with hypertension had 8 times higher odds of skin necrosis [odd ratio (OR), 8.10, P < 0.001]. Patients with TE intraoperative fill volumes >300 cm3 had 10 times higher odds of skin necrosis (OR, 10.66, P =0.010). Volumes >400 cm3 had 15 times higher odds of skin necrosis (OR, 15.56, P = 0.002). Mastectomy specimen weight was correlated with skin necrosis. Specimens >500 g had 10 times higher odds of necrosis and specimens >1000 g had 18 times higher odds of necrosis (OR, 10.03 and OR, 18.43; P =0.003 and P <0.001, respectively). Mastectomy skin necrosis was associated with a 50% increased inpatient charge. Conclusion: Mastectomy flap necrosis is associated with HTN, larger TE volumes and mastectomy specimen weights, resulting in increased inpatient charges. Conservative TE volumes should be considered for patients with hypertension and larger mastectomy specimens.
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Roberts A, Baxter N, Camacho X, Lau C, Zhong T. Once is Rarely Enough: A Population-Based Study of Reoperations after Postmastectomy Breast Reconstruction. Ann Surg Oncol 2015. [PMID: 26202563 DOI: 10.1245/s10434-015-4716-8] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
PURPOSE Postmastectomy breast reconstruction (PMBR) aims to surgically restore a breast mound following mastectomy. However, additional surgical procedures after PMBR can lead to increased postsurgical morbidity and healthcare utilization. The primary purpose of our study was to determine the overall population-based reoperation rates following PMBR in Ontario, Canada. METHODS We conducted a population-based retrospective cohort study that included women aged 18-65 years who underwent a prophylactic or therapeutic mastectomy with immediate or delayed PMBR between April 1, 2002 and March 31, 2008. Reoperations to the breast or donor site used for reconstruction were identified using the Ontario Health Insurance Plan billing codes submitted by general or plastic surgeons. Reoperations were categorized as anticipated, unanticipated major, unanticipated minor, or oncologic. Patients were followed from the date of their PMBR to March 31, 2013, or death. RESULTS Overall, 3972 women underwent PMBR between April 1, 2002 and March 31, 2008. Among them, 3504 (88%) underwent at least one reoperation during an average follow-up of 5.1 years. The median number of procedures per patient was two (mean 2.4, range 0-26). One of ten patients had three or more unanticipated major reoperations during the follow-up period. CONCLUSIONS Our results provide the first long-term population-level data on the current state of PMBR reoperation rates. The results from this study will inform patient-physician surgical decision-making and provide quantitative expectations of morbidity related to PMBR.
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Affiliation(s)
- Amanda Roberts
- Department of Surgery, University of Toronto, Toronto, ON, Canada,
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Caterson SA, Carty MJ, Helliwell LA, Hergrueter CA, Pribaz JJ, Sinha I. Evolving options for breast reconstruction. Curr Probl Surg 2015; 52:192-224. [DOI: 10.1067/j.cpsurg.2015.04.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2015] [Accepted: 04/08/2015] [Indexed: 01/11/2023]
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Rise in Microsurgical Free-Flap Breast Reconstruction in Academic Medical Practices. Ann Plast Surg 2015; 74 Suppl 1:S62-5. [DOI: 10.1097/sap.0000000000000483] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Risks and Benefits of Using an Absorbable Mesh in One-Stage Immediate Breast Reconstruction. Plast Reconstr Surg 2015; 135:498e-507e. [DOI: 10.1097/prs.0000000000001027] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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108
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ASPS Clinical Practice Guideline Summary on Breast Reconstruction with Expanders and Implants. Plast Reconstr Surg 2014; 134:648e-655e. [DOI: 10.1097/prs.0000000000000541] [Citation(s) in RCA: 87] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Um GT, Chang J, Louie O, Colohan SM, Said HK, Neligan PC, Mathes DW. Implantable Cook-Swartz Doppler probe versus Synovis Flow Coupler for the post-operative monitoring of free flap breast reconstruction. J Plast Reconstr Aesthet Surg 2014; 67:960-6. [DOI: 10.1016/j.bjps.2014.03.034] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2014] [Revised: 03/18/2014] [Accepted: 03/30/2014] [Indexed: 11/24/2022]
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Comparison of Outcomes Using AlloDerm Versus FlexHD for Implant-Based Breast Reconstruction. Ann Plast Surg 2014; 72:503-7. [DOI: 10.1097/sap.0b013e318268a87c] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Manahan MA, Prucz RB, Shridharani SM, Baltodano PA, Rosson GD. Long-term follow-up of changing practice patterns in breast reconstruction due to increased use of tissue expanders and perforator flaps. Microsurgery 2014; 34:595-601. [PMID: 24665002 DOI: 10.1002/micr.22245] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2013] [Revised: 02/26/2014] [Accepted: 03/07/2014] [Indexed: 11/09/2022]
Abstract
BACKGROUND As the science of breast reconstruction evolves, significant changes in reconstruction strategies and outcomes are expected. The purpose of this study is to determine the changes in breast reconstruction trends and outcomes that occurred at a multidisciplinary academic institution during the last decade. METHODS We compared 265 patients over two distinct 6-month intervals separated by 5 years (2002 vs. 2007) and performed long-term follow-up (4.75 ± 3.38 years 2002, 2.99 ± 2.25 years 2007). We studied patients seeking prophylactic mastectomy, patients with early breast cancer, and patients with locally advanced disease. We analyzed demographic data, breast cancer history and treatment, type and timing of reconstruction, and complications. RESULTS Implant to flap reconstruction ratio was 48:49 in 2002 and 76:102 in 2007. Use of transverse rectus abdominis myocutaneous flap declined from 57 to 4%; conversely, deep inferior epigastric perforator flap increased from 27 to 91% (P < 0.001). Correspondingly, donor site chronic pain (4 vs. 0, P = 0.012) and postoperative abdominal wall bulge (9 vs. 3, P = 0.004) rates decreased. Timing of reconstruction showed increased staged cases in 2007 compared to 2002 (P = 0.045). Post-final reconstruction radiation therapy was reduced in 2007 (P = 0.016), with subsequent lower rates of implant rupture (P < 0.001). CONCLUSIONS At our institution and over the last decade, increasing staged reconstructions have successfully reduced the rates of post-final reconstruction radiotherapy with optimized outcomes. Contrary to national trends, the rates of autologous flap reconstructions have increased with reduced donor site morbidity. This suggests that academic breast reconstruction trends are independent from national trends.
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Affiliation(s)
- Michele A Manahan
- Department of Plastic and Reconstructive Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD
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The increased risk of adverse outcomes in bilateral deep inferior epigastric artery perforator flap breast reconstruction compared to unilateral reconstruction: A systematic review and meta-analysis. J Plast Reconstr Aesthet Surg 2014; 67:143-56. [DOI: 10.1016/j.bjps.2013.10.024] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2013] [Revised: 10/13/2013] [Accepted: 10/14/2013] [Indexed: 01/29/2023]
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Three words to the wise: high-risk algorithm. Plast Reconstr Surg 2014; 133:198-199. [PMID: 24374680 DOI: 10.1097/01.prs.0000435842.10799.ef] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Hoppe DL, Ueberreiter K, Surlemont Y, Peltoniemi H, Stabile M, Kauhanen S. Breast reconstruction de novo by water-jet assisted autologous fat grafting--a retrospective study. GERMAN MEDICAL SCIENCE : GMS E-JOURNAL 2013; 11:Doc17. [PMID: 24403878 PMCID: PMC3884560 DOI: 10.3205/000185] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/06/2013] [Revised: 11/15/2013] [Indexed: 12/20/2022]
Abstract
BACKGROUND Autologous fat grafting has become a frequent, simple, reproducible and low-risk technique for revisional or partial breast reconstruction. The presented European multicenter study describes an optimized treatment and follow-up protocol for the de novo breast reconstruction after total mastectomy by lipotransfer alone. METHODS A retrospective European multicenter trial included 135 procedures on 28 (35 breasts) postmastectomy patients (mean 52.4 years). All women were treated with the water-jet assisted fat grafting method (BEAULI™) combined with additional procedures (NAC reconstruction, contralateral mastoplasty) and evaluated with at least 6 months follow-up (mean 2.6 years). Sonography or mammography, clinical examination, patient questionnaire (10-point Likert scale) and digital photographs were carried out. RESULTS On average the patients received 4 to 6 procedures each with a single volume of 159 ml (±61 ml) over 21 months (range 9 months to 2.5 years). In total 1,020 ml (±515 ml) fat were grafted till a complete breast reconstruction was achieved. Irradiated patients needed a significantly higher volume than non-irradiated (p<0.041). Main treatment complications were liponecrosis (2.59%), infection (0.74%) and granuloma (0.74%). Patient satisfaction was overall high to very high (96%) and confirmed the good aesthetic results (68%) and the natural softness, contour and shape of the reconstructed breast. CONCLUSIONS A complete breast reconstruction with large volume fat grafting is alternatively possible to standard techniques in selected cases. It takes at least 4 to 6 lipotransfers in the course of 2 years. Patients with prior radiotherapy may require even up to 8 sessions over nearly 3 years of treatment.
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Affiliation(s)
- Delia Letizia Hoppe
- BG Unfallklinik Tübingen, Klinik für Hand-, Plastische, Rekonstruktive und Verbrennungschirurgie, Tübingen, Germany
| | | | - Yves Surlemont
- Clinique Saint Antoine, Rouen University Hospital, Paediatric and Dermatologic Plastic Surgery, Bois Guillaume, France
| | | | | | - Susanna Kauhanen
- Helsinki University Hospital, Department of Plastic and Reconstructive Surgery, Helsinki, Finland
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Sood M, Glat P. Potential of the SPY intraoperative perfusion assessment system to reduce ischemic complications in immediate postmastectomy breast reconstruction. ANNALS OF SURGICAL INNOVATION AND RESEARCH 2013; 7:9. [PMID: 23875697 PMCID: PMC3733811 DOI: 10.1186/1750-1164-7-9] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/23/2013] [Accepted: 07/17/2013] [Indexed: 11/10/2022]
Abstract
BACKGROUND The quality and viability of mastectomy flaps remain a central challenge in reconstructive surgery, particularly for immediate breast reconstruction. Insufficient perfusion in tissue flaps is a leading cause of early complications following reconstructive procedures, and clinical judgment alone is not completely reliable for the assessment of flap viability. Accurate and reliable intraoperative methods for assessment of tissue perfusion are needed to help surgeons identify tissue at risk for ischemia and necrosis, thereby allowing for maneuvers to improve tissue flap viability. METHODS This study evaluates the use of intraoperative laser angiography using the SPY System (LifeCell Corp., Branchburg, NJ) for the assessment of perfusion in mastectomy flaps for immediate breast reconstruction. The SPY System uses the contrast agent indocyanine green, which has an excellent safety profile and pharmacokinetics that allow for repeat evaluations during the same surgical procedure. In recent work, the SPY System has demonstrated high sensitivity and specificity for detection of tissues at risk for ischemia and necrosis during reconstructive surgery. Using a retrospective, chart-review design, the authors compared consecutive cases of immediate breast reconstruction using a prosthesis, before and after implementation of the SPY System. RESULTS Ninety-one subjects were included in the analysis: 52 prior to SPY (Pre-SPY) and 39 after implementation of SPY (Post-SPY). Baseline characteristics were similar between the groups. Both groups had high rates of comorbidities, chemotherapy, and radiation therapy. The rate of postoperative complications was two-fold higher in the Pre-SPY group compared to the Post-SPY group (36.5% vs. 17.9%); this difference was of borderline significance (P = 0.0631). However, mean number of repeat visits to the OR per patient was significantly higher in the Pre-SPY group (1.21 ± 1.47 vs. 0.41 ± 0.71; P = 0.0023). Of the seven patients with complications in the Post-SPY group, five were identified by SPY as having poor flap perfusion; none were identified by clinical judgment alone. CONCLUSIONS This study suggests that the SPY System can contribute to reduced ischemia-related complications in a population of women undergoing immediate breast reconstruction following mastectomy for breast cancer.
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Affiliation(s)
- Mohit Sood
- Philadelphia College of Osteopathic Medicine, Cherry Hill, New Jersey.
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Fischer JP, Nelson JA, Au A, CT T, Serletti JM, Wu LC. Complications and morbidity following breast reconstruction – a review of 16,063 cases from the 2005–2010 NSQIP datasets. J Plast Surg Hand Surg 2013; 48:104-14. [DOI: 10.3109/2000656x.2013.819003] [Citation(s) in RCA: 85] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
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Lang JE, Summers DE, Cui H, Carey JN, Viscusi RK, Hurst CA, Waer AL, Ley MLB, Sener SF, Vijayasekaran A. Trends in post-mastectomy reconstruction: a SEER database analysis. J Surg Oncol 2013; 108:163-8. [PMID: 23861196 DOI: 10.1002/jso.23365] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2013] [Accepted: 05/30/2013] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND OBJECTIVES This study was performed to investigate recent trends and factors associated with immediate breast reconstruction (IBR) using a large population-based registry. We hypothesized that rates of IBR have increased since passage of the Women's Health and Cancer Rights Act of 1998. METHODS The SEER (surveillance, epidemiology and end results) database was used to evaluate Stage I-III breast cancer (BC) patients who underwent total mastectomy from 1998 to 2008. Univariate and multivariate analyses were performed to study predictors of IBR. RESULTS Of 112,348 patients with BC treated by mastectomy 18,001 (16%) had IBR. Rates of IBR increased significantly from 1998 to 2008 (P < 0.0001). Use of IBR significantly decreased as patient age increased (P < 0.0001), as stage increased (P < 0.0001), and as the number of positive lymph nodes increased (P < 0.0001). Estrogen receptor+/progesterone receptor+ (ER+/PR+) patients had significantly higher IBR rates than ER-/PR-patients (P < 0.0001). IBR was used in 3,615 of 25,823 (14.0%) of patients having post-mastectomy radiation (XRT) and in 14,188 of 86,513 (16.4%) of those not having XRT (P < 0.0001). CONCLUSIONS The utilization of IBR has increased significantly over the last decade. IBR was found to be significantly associated with age, race, geographical region, stage, ER, grade, LN status, and XRT (P < 0.0001).
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Affiliation(s)
- Julie E Lang
- Norris Comprehensive Cancer Center, University of Southern California, Los Angeles, California, USA.
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440 Consecutive immediate, implant-based, single-surgeon breast reconstructions in 281 patients: a comparison of early outcomes and costs between SurgiMend fetal bovine and AlloDerm human cadaveric acellular dermal matrices. Plast Reconstr Surg 2013; 131:940-951. [PMID: 23629076 DOI: 10.1097/prs.0b013e3182865ab3] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND A 2010 nationwide survey of plastic and reconstructive surgeons indicated that approximately 83 percent performed predominantly implant-based breast reconstruction, with acellular dermal matrix used by approximately half of those practitioners. Although the medical literature documents well over 2000 cases of breast reconstruction with matrices, relatively few cases using other than human cadaveric acellular dermal matrices have been reported. The author compared complications and costs using SurgiMend fetal bovine and AlloDerm human cadaveric acellular dermal matrices. METHODS A retrospective review of a single surgeon's 5-year experience was performed for consecutive, nonrandomized immediate breast reconstructions with acellular dermal matrix from 2005 to 2010. RESULTS Two hundred eighty-one patients had 440 implant-based reconstructions using SurgiMend [222 patients (79.0 percent)] or AlloDerm [59 patients (21.0 percent)]. No significant differences in complication rates were observed between SurgiMend and AlloDerm for hematoma, infection, major skin necrosis, or breast implant removal. Seroma was the most prevalent complication; the seroma rate for AlloDerm (15.7 percent) was significantly greater than that for SurgiMend (8.3 percent). Using recent product costs for equivalently sized AlloDerm and SurgiMend units, the cost of SurgiMend was $1024 less per breast than AlloDerm. CONCLUSIONS SurgiMend fetal bovine and AlloDerm human cadaveric acellular dermal matrices demonstrate similar rates of major early complications in breast reconstruction in this study. This similarity in complication rates between SurgiMend and AlloDerm and the cost savings seen with the use of SurgiMend are factors for the surgeon to consider in choosing a matrix for breast reconstruction. CLINICAL QUESTION/LEVEL OF EVIDENCE : Therapeutic, III.
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Laporta R, Longo B, Pagnoni M, Catta F, Garbarino GM, Santanelli F. Accidental injury of the latissimus dorsi flap pedicle during axillae dissection: Types and reconstruction algorithm. Microsurgery 2013; 34:5-9. [DOI: 10.1002/micr.22112] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2012] [Revised: 02/26/2013] [Accepted: 03/01/2013] [Indexed: 11/10/2022]
Affiliation(s)
- Rosaria Laporta
- Plastic Surgery Unit; Sant'Andrea Hospital; School of Medicine and Psychology, “Sapienza” University of Rome; Italy
| | - Benedetto Longo
- Plastic Surgery Unit; Sant'Andrea Hospital; School of Medicine and Psychology, “Sapienza” University of Rome; Italy
| | - Marco Pagnoni
- Plastic Surgery Unit; Sant'Andrea Hospital; School of Medicine and Psychology, “Sapienza” University of Rome; Italy
| | - Federico Catta
- Plastic Surgery Unit; Sant'Andrea Hospital; School of Medicine and Psychology, “Sapienza” University of Rome; Italy
| | - Giovanni Maria Garbarino
- Plastic Surgery Unit; Sant'Andrea Hospital; School of Medicine and Psychology, “Sapienza” University of Rome; Italy
| | - Fabio Santanelli
- Plastic Surgery Unit; Sant'Andrea Hospital; School of Medicine and Psychology, “Sapienza” University of Rome; Italy
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Mioton LM, Smetona JT, Hanwright PJ, Seth AK, Wang E, Bilimoria KY, Gaido J, Fine NA, Kim JYS. Comparing thirty-day outcomes in prosthetic and autologous breast reconstruction: a multivariate analysis of 13,082 patients? J Plast Reconstr Aesthet Surg 2013; 66:917-25. [PMID: 23562485 DOI: 10.1016/j.bjps.2013.03.009] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2012] [Revised: 11/20/2012] [Accepted: 03/05/2013] [Indexed: 11/17/2022]
Abstract
BACKGROUND There is a paucity of multi-institutional data that directly compares short term outcomes of autologous and prosthetic breast reconstruction. The National Surgical Quality Improvement Program provides a unique data platform for evaluating peri-operative outcomes of these two main categories of breast reconstruction. It has detailed data from nearly 250 hospitals and over 13,000 patients. We performed risk-adjusted analysis of prosthetic and autologous breast reconstruction to compare 30-day morbidity outcomes. METHODS Patients who underwent prosthetic breast reconstruction or autologous tissue reconstruction from 2006 to 2010 were identified using operation descriptions. Over 240 tracked variables were extracted for patients undergoing breast reconstruction. Thirty-day postoperative outcomes were compared, and subgroup analysis was performed on the autologous population to describe outcomes of specific flap procedures. Reconstruction was analyzed as an independent risk factor for specific complications, with propensity scores used to help standardize compared patient populations. Regression analyses were performed using SPSS (version 20.0, Chicago, IL). RESULTS A total of 13,082 patients underwent breast reconstruction; 9786 patients received prosthetic reconstruction and 3296 received autologous reconstruction. Within the autologous cohort, 1608 (48.8%) patients underwent a pedicle TRAM flap, 1079 (32.7%) had a LD flap, and 609 (18.5%) received a free flap. Autologous reconstruction patients had higher rates of overall complications (12.47% vs 5.38%, p<.001), wound infection (5.46% vs 3.45%, p<.001), prosthesis/flap failure (3.13% vs 0.85%, p<.001), and reoperation (9.59% vs 6.76%, p<.001). Risk-adjusted multivariate analysis also showed autologous reconstruction to be a significant independent predictor of specific short term outcomes. CONCLUSIONS Using risk-adjusted models of a large multi-institutional database, we found that--relative to prosthetic reconstruction--autologous reconstruction had higher rates of 30-day overall complications, wound infection, prosthesis/flap failure, and reoperation. This may be due, in part, to a concomitant increase in operative time and higher case complexity. Taken with other reports such as NMBRA, this study helps to educate patients and surgeons alike on potential, comparative complications during the perioperative period.
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Affiliation(s)
- Lauren M Mioton
- Department of Plastic Surgery, Vanderbilt School of Medicine, Nashville, TN, USA
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Trends in tertiary breast reconstruction: Literature review and single centre experience. Breast 2013; 22:173-178. [DOI: 10.1016/j.breast.2012.06.004] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2011] [Revised: 05/26/2012] [Accepted: 06/07/2012] [Indexed: 11/20/2022] Open
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Szychta P, Butterworth M, Dixon M, Kulkarni D, Stewart K, Raine C. Breast reconstruction with the denervated latissimus dorsi musculocutaneous flap. Breast 2013; 22:667-72. [PMID: 23374963 DOI: 10.1016/j.breast.2013.01.001] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2012] [Revised: 11/08/2012] [Accepted: 01/06/2013] [Indexed: 10/27/2022] Open
Abstract
OBJECTIVE To analyze clinical implications of the thoracodorsal nerve division in the latissimus dorsi musculocutaneous flap breast reconstruction. PATIENTS AND METHODS Prospective cohort study was conducted on 29 patients. Breast reconstruction with latissimus dorsi musculocutaneous flap was performed unilaterally in 20 patients or bilaterally in 9 women (38 breasts). Thoracodorsal nerve was divided during reconstruction of 20 breasts (group 1) and was preserved for 18 breasts (group 2). Height, width, projection, area of the covering skin and volume of the reconstructed and healthy breasts were measured on the 3D images of the anterior chest wall, taken 6 weeks and 6 months postoperatively with the Di3D 3D camera. Data regarding tissue consistency, painfulness and animation of the reconstructed breast, symmetry of both breasts and overall satisfaction after the surgery were collected at 6 months. RESULTS The reconstructed and healthy breasts decreased in volume in group 1 (-45.85 cm(3) ± 48.41 cm(3), p = 0.0004; -29.13 cm(3) ± 14.98 cm(3), p = 0.0009) and in group 2 (-31.5 cm(3) ± 25.35 cm(3), p = 0.0001; -15.4 cm(3) ± 21.96 cm(3), p = 0.0537). There were no differences in decrease in volume between groups 1 and 2 (p > 0.05). Respondents in group 1 in comparison to group 2 showed similar satisfaction of the tissue consistency of the reconstructed breast (p > 0.05) and the level of symmetry between both breasts (p > 0.05), gave lower scores for painfulness (p < 0.0001), animation (p < 0.0001) and higher scores for the overall satisfaction about the reconstructed breast (p = 0.0001). CONCLUSION We suggest that division of the thoracodorsal nerve during latissimus dorsi musculocutaneous flap breast reconstruction is a useful undertaking to minimize unnatural animation of the reconstructed breast.
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Affiliation(s)
- Pawel Szychta
- Plastic and Reconstructive Surgery Department, St John's University Hospital, Howden Road West, Livingston, West Lothian, EH54 6PP, United Kingdom; Department of Oncological Surgery and Breast Diseases, Polish Mother's Memorial Hospital-Research Institute, Lodz, Poland.
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Dean NR, Yip JM, Birrell S. Rotation flap approach mastectomy. ANZ J Surg 2012; 83:139-45. [PMID: 23171002 DOI: 10.1111/ans.12008] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/05/2012] [Indexed: 11/30/2022]
Abstract
BACKGROUND The authors present a technique for mastectomy with greater versatility for reconstruction. METHODS The areola is marked and a vertical line is dropped medial to the breast axis, down towards the inframammary fold and laterally to the anterior axillary line. In large ptotic breasts, the markings are modified to reduce the skin envelope. The rotation flap is raised over the lateral half of the breast, and the remainder of the skin envelope is then separated from the breast tissue as per any other mastectomy. Skin closure is by rotation of the flap and incremental gathering of skin. An audit of 37 cases of rotation flap approach (RoFA) mastectomy has been performed, evaluating complications and post-reconstruction outcome using the BREAST Q. RESULTS RoFA has been found to offer good access for mastectomy and lymphadenectomy. A total of 7 of 37 patients had delay in healing, and 2 patients developed haematoma. Post-reconstruction outcome was scored as comparable with other published series. DISCUSSION The RoFA mastectomy has the potential to facilitate reconstructive results equivalent to skin-sparing mastectomy and immediate reconstruction.
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Affiliation(s)
- Nicola R Dean
- Flinders Medical Centre, Adelaide, South Australia, Australia.
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125
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Abstract
INTRODUCTION Surgical site infections (SSI) are a source of significant postoperative morbidity and cost. Although immediate breast reconstruction after mastectomy has become routine, the data regarding the incidence of SSI in immediate breast reconstruction is highly variable and series dependent. METHODS Using the National Surgical Quality Improvement Program database, all female patients undergoing mastectomy, with or without immediate reconstruction, from 2005 to 2009 were identified. Only "clean" procedures were included. The primary outcome was incidence of SSI within 30 days of operation. Stepwise logistic regression analysis was used to identify risk factors associated with SSI. RESULTS A total of 48,393 mastectomies were performed during the study period, of which 9315 (19.2%) had immediate breast reconstruction. The incidence of SSI was 3.5% (330/9315) (95% CI [confidence interval]: 3.2%-4%) in patients undergoing mastectomy with reconstruction and 2.5% (966/39,078) (95% CI: 2.3%-2.6%) in patients undergoing mastectomy without reconstruction (P < 0.001). Independent risk factors for SSI include increased preoperative body mass index (BMI), heavy alcohol use, ASA (American Society of Anesthesiologists) score greater than 2, flap failure, and operative time of 6 hours or longer. CONCLUSIONS Immediate breast reconstruction is associated with a statistically significant increase in risk of SSI in patients undergoing mastectomy (3.5% vs 2.5%). However, this difference was not considered to be clinically significant. In this large series, increased BMI, alcohol use, ASA class greater than 2, flap failure, and prolonged operative time were associated with increased risk of SSI.
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126
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Rykała J, Szychta P, Kruk-Jeromin J. Delayed two-stage breast reconstruction with implants: The authors' recent experience. THE CANADIAN JOURNAL OF PLASTIC SURGERY = JOURNAL CANADIEN DE CHIRURGIE PLASTIQUE 2012; 19:88-92. [PMID: 22942657 DOI: 10.1177/229255031101900306] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Presently, breast cancer detection is delayed in Poland and, thus, the only other option for patients is amputation and breast reconstruction (immediate or delayed). Reconstructive methods are based on using the patient's own tissue (pedicled or free myocutaneous flaps) or implants (a tissue expander, which is later exchanged for a prosthesis or an expandable implant). OBJECTIVE To evaluate the aesthetic results of a delayed two-stage breast reconstruction with the use of implants (expander and prosthesis) in patients who have previously undergone cancer-related mastectomy. METHODS From 2006 to 2009, 54 patients (34 to 65 years of age) underwent reconstruction at least one year after their mastectomy and adjuvant chemotherapy; three women also received x-ray therapy. All women underwent a two-stage treatment with a tissue expander, which was later exchanged for a prosthesis. RESULTS Outcomes of the surgery (evaluated by the physician and the patient at least six months after all stages of reconstruction) were found to be very good in 42 patients and good in 12 patients. After amputation and x-ray therapy in two cases, a fistula developed, which necessitated implant removal. CONCLUSIONS After amputation, breast reconstruction with implants (expander and prosthesis) provides good aesthetic results. The method is mildly burdening to the patient and does not cause severe scarring. Symmetrization of the second breast is often recommended; however, the cost is not covered by the national health system. In principle, earlier x-ray therapy disqualifies the application of implants. Dividing reconstruction into two stages (expander and prosthesis) allows for possible correction of prosthesis placement.
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Affiliation(s)
- Jan Rykała
- Plastic, Reconstructive and Aesthetic Surgery Department, Medical University of Lodz, Poland
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de Wildt RP, Enajat M, Sawor JH, Fresow RNGM, Nanhekhan LV, van der Hulst RRWJ. The unilateral deep inferior epigastric perforator flap: Comparing university to community hospital. J Plast Surg Hand Surg 2012; 46:159-62. [DOI: 10.3109/2000656x.2012.686915] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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128
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Ho G, Nguyen TJ, Shahabi A, Hwang BH, Chan LS, Wong AK. A systematic review and meta-analysis of complications associated with acellular dermal matrix-assisted breast reconstruction. Ann Plast Surg 2012; 68:346-56. [PMID: 22421476 DOI: 10.1097/sap.0b013e31823f3cd9] [Citation(s) in RCA: 232] [Impact Index Per Article: 19.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND Multiple outcome studies have been published on the use of acellular dermal matrix (ADM) in breast reconstruction with disparate results. The purpose of this study was to conduct a systematic review and meta-analysis to determine an aggregate estimate of risks associated with ADM-assisted breast reconstruction. METHODS The MEDLINE, Web of Science, and Cochrane Library databases were queried, and relevant articles published up to September 2010 were analyzed based on specific inclusion criteria. Seven complications were studied including seroma, cellulitis, infection, hematoma, skin flap necrosis, capsular contracture, and reconstructive failure. A pooled random effects estimate for each complication and 95% confidence intervals (CI) were derived. For comparisons of ADM and non-ADM, the pooled random effects odds ratio (OR) and 95% CI were derived. Heterogeneity was measured using the I2 statistic. RESULTS Sixteen studies met the inclusion criteria. The pooled complication rates were seroma (6.9%; 95% CI, 5.3%-8.8%), cellulitis (2.0%; 95% CI, 1.2%-3.1%), infection (5.7%; 95% CI, 4.3%-7.3%), skin flap necrosis (10.9%; 95% CI, 8.7%-13.5%), hematoma (1.3%; 95% CI, 0.6%-2.4%), capsular contracture (0.6%; 95% CI, 0.1%-1.7%), and reconstructive failure (5.1%; 95% CI, 3.8%-6.7%). Five studies reported findings for both the ADM and non-ADM patients and were used in the meta-analysis to calculate pooled OR. ADM-assisted breast reconstructions had a higher likelihood of seroma (pooled OR, 3.9; 95% CI, 2.4-6.2), infection (pooled OR, 2.7; 95% CI, 1.1-6.4), and reconstructive failure (pooled OR, 3.0; 95% CI, 1.3-6.8) than breast reconstructions without the use of ADM. The relation of ADM use to hematoma (pooled OR, 2.0; 95% CI, 0.8-5.2), cellulitis (pooled OR, 2.0; 95% CI, 0.9-4.3), and skin flap necrosis (pooled OR, 1.9; 95% CI, 0.6-5.4) was inconclusive. CONCLUSIONS In the studies evaluated, ADM-assisted breast reconstructions exhibited a higher likelihood of seroma, infection, and reconstructive failure than prosthetic-based breast reconstructions using traditional musculofascial flaps. ADM is associated with a lower rate of capsular contracture. A careful risk/benefit analysis should be performed when choosing to use ADM in implant-based breast reconstruction.
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Affiliation(s)
- Goretti Ho
- Division of Plastic and Reconstructive Surgery, Keck School of Medicine of University of Southern California, Los Angeles, CA 90033, USA
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129
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Martano A, Malata CM. Accidental latissimus dorsi flap pedicle avulsion during immediate breast reconstruction: salvage by conversion to free flap. J Plast Reconstr Aesthet Surg 2012; 65:1107-10. [PMID: 22386666 DOI: 10.1016/j.bjps.2012.01.017] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2011] [Revised: 01/17/2012] [Accepted: 01/26/2012] [Indexed: 11/19/2022]
Abstract
Pedicle damage is a rare complication of latissimus dorsi (LD) flap breast reconstruction. We report a case of accidental avulsion of the vascular pedicle of a totally autologous (extended) LD flap during immediate breast reconstruction in a patient who had previously undergone contralateral breast reconstruction with a pedicled TRAM flap based on the opposite superior epigastric vessels. The intra-operative strategy to salvage the avulsed LD flap by conversion to a free flap while not compromising the contralateral breast reconstruction is discussed.
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Affiliation(s)
- A Martano
- Department of Plastic Surgery, University of Rome La Sapienza, Italy
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130
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An analysis of delayed breast reconstruction outcomes as recorded in the American College of Surgeons National Surgical Quality Improvement Program. J Plast Reconstr Aesthet Surg 2012; 65:289-94. [DOI: 10.1016/j.bjps.2011.09.031] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2011] [Revised: 07/25/2011] [Accepted: 09/05/2011] [Indexed: 12/18/2022]
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Lee BT, Duggan MM, Keenan MT, Kamatkar S, Quinlan RM, Hergrueter CA, Hertl MC, Shin JH, Truppin NB, Chun YS. Commonwealth of Massachusetts Board of Registration in Medicine Expert Panel on Immediate Implant-Based Breast Reconstruction Following Mastectomy for Cancer: Executive Summary, June 2011. J Am Coll Surg 2011; 213:800-5. [DOI: 10.1016/j.jamcollsurg.2011.08.014] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2011] [Accepted: 08/15/2011] [Indexed: 11/25/2022]
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132
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Gopie JP, Timman R, Hilhorst MT, Hofer SOP, Mureau MAM, Tibben A. The short-term psychological impact of complications after breast reconstruction. Psychooncology 2011; 22:290-8. [DOI: 10.1002/pon.2089] [Citation(s) in RCA: 55] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2011] [Revised: 09/21/2011] [Accepted: 09/26/2011] [Indexed: 01/22/2023]
Affiliation(s)
- Jessica P. Gopie
- Centre for Human and Clinical Genetics; Leiden University Medical Center; Leiden The Netherlands
| | - Reinier Timman
- Department of Medical Psychology and Psychotherapy; Erasmus University Medical Center; Rotterdam The Netherlands
| | - Medard T. Hilhorst
- Department of Medical Ethics and Philosophy; Erasmus University Medical Center; Rotterdam The Netherlands
| | - Stefan O. P. Hofer
- Division of Plastic Surgery, University Health Network; University of Toronto; Toronto ON Canada
| | - Marc A. M. Mureau
- Department of Plastic and Reconstructive Surgery; Erasmus University Medical Center; Rotterdam The Netherlands
| | - Aad Tibben
- Centre for Human and Clinical Genetics; Leiden University Medical Center; Leiden The Netherlands
- Department of Clinical Genetics; Erasmus University Medical Center; Rotterdam The Netherlands
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133
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Complications in immediate breast reconstruction after mastectomy. Int J Technol Assess Health Care 2011; 27:298-304. [DOI: 10.1017/s026646231100047x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Objectives: Immediate post-mastectomy breast reconstruction (IBR) is a procedure that has proven advantages, but it also entails risks. The aim of this study was to identify risk factors for reconstruction failure.Methods: A review was made of all the IBR carried out at a general hospital from 2002 to 2009. Retrospective information was obtained about postoperative complications and the characteristics of patients and treatments applied. The minimum follow-up period was 9 months. Cox's regression analysis was performed on the variables related to the reconstruction failure requiring the removal of the prosthesis, with an explanatory model in which all the study variables were introduced and a predictive model that contained only the variables known before the intervention.Results: A total of 115 IRB interventions carried out on 112 women with breast cancer were analyzed. The mean follow-up period was 25.5 months. In sixty cases (52.2 percent), there were no complications; in sixteen cases (13.9 percent) minor complications appeared, and in 39 (33.9 percent) the complications were moderate. In twenty-six cases (22.6 percent), a reconstruction failure occurred. Cox's regression model revealed that the reconstruction failures were related to the patient's age (Hazard Ratio 1.08), to neoadjuvant chemotherapy (HR 6.24) and to postoperative tamoxifen (HR 3.10). The predictive model included the age of the patient (HR 1.05) and the use of neoadjuvant chemotherapy (HR 5.11).Conclusions: A significant proportion of the patients receiving IBR developed reconstruction failure. Multivariate analysis identified three variables related to this complication, two of which were known before the intervention.
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Hvilsom GB, Friis S, Frederiksen K, Steding-Jessen M, Henriksen TF, Lipworth L, McLaughlin JK, Elberg JJ, Damsgaard TE, Hölmich LR. The clinical course of immediate breast implant reconstruction after breast cancer. Acta Oncol 2011; 50:1045-52. [PMID: 21604960 DOI: 10.3109/0284186x.2011.581690] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND The number of women suitable for breast conserving treatment as well as immediate reconstruction after breast cancer has been increasing, and studies of complications hereafter are needed. MATERIAL AND METHODS The cohort was identified in the prospective database of the Danish Registry for Plastic Surgery of the Breast during the period 1999 to 2006; 167 women with 189 immediate breast reconstructions (40 one-stage and 149 two-stage procedures) after breast cancer without a history of radiation therapy. The women were followed for complications until November 2009. Cumulative incidence risks were computed for infection, hematoma, seroma, severe capsular contracture (modified Baker III and IV), extrusion of the implant, implant rupture, asymmetry/displacement of the implant, any complication, and reoperation. In addition, we compared the postoperative course of immediate two-stage procedures with delayed two-stage procedures. RESULTS The overall eight-year risk estimates for the immediate procedures were 76.4% for any complication, 5.3% for severe capsular contracture, 29.5% for displacement/asymmetry of the implant and 40.6% for reoperation. Significantly higher risk for reoperation was observed after immediate one-stage than after two-stage procedures. For immediate two-stage procedures acute complications such as infection, seroma and hematoma were higher in the expansion period than after the second planned surgery. Higher risks for acute complications were observed after immediate than after delayed two-stage procedures. CONCLUSION Immediate breast implant reconstruction was found to have substantial risks of complications in non-radiated women, which should be considered in the guidance of breast cancer patients before choosing reconstructive procedure.
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Affiliation(s)
- Gitte B Hvilsom
- Institute of Cancer Epidemiology, Danish Cancer Society, Copenhagen, Denmark.
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135
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Breast reconstruction in elderly women breast cancer: A review. Cancer Treat Rev 2011; 37:353-7. [DOI: 10.1016/j.ctrv.2011.02.001] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2010] [Revised: 01/28/2011] [Accepted: 02/03/2011] [Indexed: 11/20/2022]
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136
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137
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Venous thromboembolism following microsurgical breast reconstruction: an objective analysis in 225 consecutive patients using low-molecular-weight heparin prophylaxis. Plast Reconstr Surg 2011; 127:1399-1406. [PMID: 21187811 DOI: 10.1097/prs.0b013e318208d025] [Citation(s) in RCA: 61] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Free flap breast reconstruction involves major risk factors for postsurgical venous thromboembolism. The main study objectives were (1) to estimate objectively the incidence of symptomatic and asymptomatic lower extremity deep vein thrombosis in patients who received postoperative thromboprophylaxis after free flap breast reconstruction, (2) to evaluate the safety of low-molecular-weight heparin postoperatively, and (3) to assess the incidence of symptomatic pulmonary embolism or sudden death. METHODS A cohort study of 225 consecutive patients who underwent abdominally based free flap breast reconstruction at a single cancer center was conducted. The postoperative thromboprophylaxis regimen was based on the American College of Chest Physicians guidelines. A study group of 118 patients systematically underwent bilateral lower extremity duplex ultrasound before hospital discharge to assess objectively the status of the lower extremity deep venous system. A retrospective cohort of 107 women who were not systematically screened for deep vein thrombosis was used for comparison. RESULTS The incidence of postoperative deep vein thrombosis confirmed by duplex ultrasound was 3.4 percent in the study group, all events being clinically silent. Bleeding complications in the entire patient sample were estimated at 5.3 percent. Partial flap loss and total flap loss rates were 2.7 and 1.9 percent, respectively. No venous thromboembolism event was diagnosed in the control group. CONCLUSIONS This report shows that the objective incidence of deep vein thrombosis was 3.4 percent within 5 postoperative days in this patient population. The authors' findings support the use of triple thromboprophylaxis and demonstrate that low-molecular-weight heparin is a safe and effective method for prevention of venous thromboembolism in this population.
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138
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Phillips BT, Wang ED, Mirrer J, Lanier ST, Khan SU, Dagum AB, Bui DT. Current Practice Among Plastic Surgeons of Antibiotic Prophylaxis and Closed-Suction Drains in Breast Reconstruction. Ann Plast Surg 2011; 66:460-5. [DOI: 10.1097/sap.0b013e31820c0593] [Citation(s) in RCA: 78] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
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139
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The true incidence of near-term postoperative complications in prosthetic breast reconstruction utilizing human acellular dermal matrices: a meta-analysis. Aesthetic Plast Surg 2011; 35:100-6. [PMID: 21184070 DOI: 10.1007/s00266-010-9631-6] [Citation(s) in RCA: 55] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2010] [Accepted: 10/29/2010] [Indexed: 10/18/2022]
Abstract
BACKGROUND The use of human acellular dermal matrix (HADM) materials in prosthetic-based breast reconstruction has gained popularity in recent years. Questions remain, however, regarding the nature and incidence of postoperative complications associated with this technique. The results reported in the available literature vary widely. This meta-analysis examines this question further with a broad review of the available literature in an effort to better define the true nature and incidence of near-term complications associated with the use of HADM in prosthetic-based breast reconstruction. It does not aim to compare this method of reconstruction to others. METHODS A review of the available literature was performed in July 2009. The goal was to identify all previous works describing the placement of HADM at prosthetic-based breast reconstruction. Included were studies that documented the use of HADM for coverage of tissue expanders or permanent implants following therapeutic or prophylactic mastectomy. Excluded were studies that reported on the use of HADM in cosmetic breast surgery or studies that included the use of xenografts. Data collected included demographics as well as the nature and incidence of complications, with separate categories assigned for seroma, infection, flap necrosis, and "other." Data were analyzed using Comprehensive Meta-Analysis(®) software (Biostat, Englewood, NJ). Raw proportions, fixed-effect models, and random-effect models were used to assess the complication rates across studies. RESULTS Eleven published articles and one abstract that was later published as an article were identified. Within these 12 studies, a total of 789 breasts were identified that had undergone reconstruction with HADM. The mean follow-up was 13.7 months. Under the random-effects model, the total complication rate was 12.0%. The most common complications were flap necrosis (3.3%), seroma (3.3%), and infection (5.6%). All complications not included in these categories were set apart in a separate category, "Other," and totaled 3.0% CONCLUSION The true incidence of postoperative complications in the near term utilizing HADM in prosthetic-based breast reconstruction appears to be approximately 12%. The incidence of long-term complications such as capsular contracture remains unknown. However, as surgical experience with HADM grows, operative techniques designed at reducing risks will mature, strategies for managing complications will advance, and more advanced products designed to reduce the incidence of complications are likely to become available.
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Irani Y, Casanova D, Amar E. [Autologous fat grafting in radiated tissue prior to breast prosthetic reconstruction: is the technique reliable?]. ANN CHIR PLAST ESTH 2010; 57:59-66. [PMID: 21145645 DOI: 10.1016/j.anplas.2010.11.002] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2010] [Accepted: 11/04/2010] [Indexed: 01/17/2023]
Abstract
BACKGROUND Prosthetic breast reconstruction is critical in the radiated breast. The main purpose of this study was to determine whether fat grafting prior to breast reconstruction could improve thoracic tissue trophicity enough to perform a simple prosthetic reconstruction, avoiding a flap procedure. PATIENTS AND METHODS A total of 25 patients who had undergone a modified radical mastectomy followed by radiotherapy were retrieved. Fat was injected according to Coleman's technique. Prosthetic reconstruction was performed three to six months after the fat grafting procedure. Reconstruction of the nipple-areola complex was performed 3 months after implant positioning. Median follow-up interval was two years. Patient satisfaction was ascertained with a self-assessment questionnaire. Three independent blinded physician observers judged preoperative and postoperative photographs to determine the quality of reconstruction. RESULTS The mean refined fat injected volume was 160ml. In all cases except two, a unique fat grafting procedure was necessary. Prosthetic reconstruction was achieved in 23 cases. The technique failed in two cases and breast reconstruction was achieved by a latissimus dorsi flap with implant. During the follow-up interval, two complications occurred in two patients presenting with fat necrosis and oil cysts. The mean number of total surgical procedures was 2.5 per patient. Quality of reconstruction was judged as good by both physicians and patients. CONCLUSIONS Autologous fat grafting in radiated tissue prior to breast reconstruction is a safe and reliable technique. In selected cases, a simple prosthetic reconstruction can be achieved avoiding a flap procedure.
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Affiliation(s)
- Y Irani
- Service de chirurgie plastique et reconstructrice, hôpital Nord, chemin des Bourrely, 13915 Marseille cedex 20, France.
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Lee BT, Chen C, Nguyen MD, Lin SJ, Tobias AM. A new classification system for muscle and nerve preservation in DIEP flap breast reconstruction. Microsurgery 2010; 30:85-90. [PMID: 20084669 DOI: 10.1002/micr.20717] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
The main advantage of deep inferior epigastric perforator (DIEP) flap breast reconstruction is muscle preservation. Perforating vessels, however, display anatomic variability and intraoperative decisions must balance flap perfusion with muscle or nerve sacrifice. Studies that aggregate DIEP flap reconstruction may not accurately reflect the degree of rectus preservation. At Beth Israel Deaconess Medical Center from 2004-2009, 446 DIEP flaps were performed for breast reconstruction. Flaps were divided into three categories: DIEP-1, no muscle or nerve sacrifice (126 flaps); DIEP-2, segmental nerve sacrifice and minimal muscle sacrifice (244 flaps); DIEP-3, perforator harvest from both the medial and lateral row, segmental nerve sacrifice and central muscle sacrifice (76 flaps). Although the rate of abdominal bulge was similar among groups, fat necrosis was significantly higher in DIEP-1 when compared with DIEP-3 flaps (19.8% vs. 9.2%, P = 0.049). We describe a DIEP flap classification system and operative techniques to minimize muscle and nerve sacrifice.
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Affiliation(s)
- Bernard T Lee
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02215, USA.
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142
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Chen C, Nguyen MD, Bar-Meir E, Hess PA, Lin S, Tobias AM, Upton J, Lee BT. Effects of Vasopressor Administration on the Outcomes of Microsurgical Breast Reconstruction. Ann Plast Surg 2010; 65:28-31. [DOI: 10.1097/sap.0b013e3181bda312] [Citation(s) in RCA: 64] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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143
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Intraoperative perfusion mapping with laser-assisted indocyanine green imaging can predict and prevent complications in immediate breast reconstruction. Plast Reconstr Surg 2010; 125:1065-1073. [PMID: 20335859 DOI: 10.1097/prs.0b013e3181d17f80] [Citation(s) in RCA: 210] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Immediate breast reconstruction results in a superior cosmetic outcome. However, immediate breast reconstruction using both prosthetic and autologous techniques is associated with significantly higher complication rates than delayed procedures. These early postoperative complications are usually related to unrecognized ischemia of mastectomy skin and/or inadequate perfusion of autologous tissue used for reconstruction. Aside from clinical experience, there are no reliable tools to assist the novice surgeon with intraoperative assessment of tissue viability. METHODS Laser-assisted indocyanine green imaging was applied to determine and map tissue perfusion. Indocyanine green perfusion mapping was used in 24 consecutive breast reconstructions to define the perfusion of both mastectomy skin and autologous tissue. Areas of inadequate perfusion were then removed at the time of surgery. Postoperative complications occurring within 90 days after surgery were reviewed. RESULTS In 24 consecutive breast reconstruction (16 tissue expanders, two latissimus dorsi flaps, and six deep inferior epigastric perforator/superficial inferior epigastric arteries), there was a 4 percent complication rate. Intraoperatively, the use of indocyanine green imaging allowed all poorly perfused skin to be removed completely in each case, minimizing the incidence of mastectomy flap necrosis, partial necrosis of autologous tissue, and impaired healing. For autologous reconstruction, patency of anastomoses could also be confirmed. This complication rate was significantly less than the 15.1 percent complication rate observed in 206 reconstructions in the previous consecutive 148 patients (p < 0.01) with similar demographics and risk factors. CONCLUSIONS This early experience demonstrates an increased accuracy in predicting tissue necrosis (mastectomy flap, autologous tissue) as guided by indocyanine green imaging. Further prospective studies are warranted to quantify whether this technology can reduce health care costs by preventing complications in immediate breast reconstruction.
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144
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Bilateral Breast Revision Augmentation With Deep Inferior Epigastric Perforators/Superficial Inferior Epigastric Artery Flaps. Ann Plast Surg 2010; 64:416-20. [DOI: 10.1097/sap.0b013e3181b0224c] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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145
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Salgarello M, Visconti G, Farallo E. Autologous fat graft in radiated tissue prior to alloplastic reconstruction of the breast: report of two cases. Aesthetic Plast Surg 2010; 34:5-10. [PMID: 19471898 DOI: 10.1007/s00266-009-9367-3] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2009] [Accepted: 04/30/2009] [Indexed: 11/25/2022]
Abstract
BACKGROUND The new indications for radiotherapy in the cure of breast cancer lead to an increasing number of candidates for this adjuvant treatment. However, it raises some concerns with respect to the prosthetic reconstruction of the breast. In fact, the use of implants in the irradiated breast is discouraged by many authors because of the high rate of complications. In these cases autologous tissue reconstruction is being recommended. However, not every patient is a candidate for autologous tissue reconstruction. Furthermore, not all radiotherapies are comparable in dose, timing, and patient tolerance. In this article we present the preliminary results of an alternative surgical management in oncoplastic breast surgery consisting of fat injections before implant placement. METHODS Six months after the last radiation treatment, a lumpectomy patient and a modified radical mastectomy patient each underwent two sessions of fat injection prior to implant placement, with a 3-month interval in between sessions. The implants were placed 3 months after the last fat injection. RESULTS There was a 12-month follow-up for the modified radical mastectomy case and a 18-month follow-up for the lumpectomy case. In both cases we report no postoperative complications, Baker grade 1 capsule contracture, good aesthetic outcome, and high patient satisfaction. CONCLUSION The preliminary results show that fat injection in irradiated tissue prior to breast alloplastic reconstruction may reduce the radiation-related complications on implants. Benefits from fat grafting are in keeping with the theoretical basis of this surgery. Larger studies are needed to confirm our observations.
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Affiliation(s)
- Marzia Salgarello
- Department of Plastic and Reconstructive Surgery, Catholic University of Sacro Cuore, University Hospital A. Gemelli, Largo A. Gemelli 8, 00168, Rome, Italy.
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Lykoudis EG, Ziogas DE, Papanikolaou GE. Vascular pedicle avulsion in free flap breast reconstruction: A case of diep flap salvage following early avulsion of venous anastomosis and literature review. Microsurgery 2010; 30:233-7. [DOI: 10.1002/micr.20738] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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Establishment of Perforator Flap Programs for Breast Reconstruction: The New England Program Experience. Plast Reconstr Surg 2009; 124:1410-1418. [DOI: 10.1097/prs.0b013e3181b989a5] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Throckmorton AD, Boughey JC, Boostrom SY, Holifield AC, Stobbs MM, Hoskin T, Baddour LM, Degnim AC. Postoperative Prophylactic Antibiotics and Surgical Site Infection Rates in Breast Surgery Patients. Ann Surg Oncol 2009; 16:2464-9. [DOI: 10.1245/s10434-009-0542-1] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2009] [Revised: 05/13/2009] [Accepted: 05/15/2009] [Indexed: 11/18/2022]
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Agaoglu G, Erol OO. Delayed breast reconstruction with latissimus dorsi flap. Aesthetic Plast Surg 2009; 33:413-20. [PMID: 19340480 DOI: 10.1007/s00266-009-9338-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2008] [Accepted: 03/06/2009] [Indexed: 10/20/2022]
Abstract
BACKGROUND The ideal method of breast reconstruction should be safe, reliable, and have minimal or no donor-site morbidity. We present our experience with the latissimus dorsi musculocutaneous flap for delayed breast reconstruction with immediate permanent implant insertion. METHODS The latissimus dorsi musculocutaneous flap was performed on patients who presented for delayed breast reconstruction. From 1999 to 2007, charts of patients were reviewed for age, type of mastectomy, history of chest wall irradiation, nipple-areola complex reconstruction, and complications at both the donor site and the reconstructed breast site. RESULTS The latissimus dorsi was used as a musculocutaneous flap in 33 patients who had breast cancer surgery. The mean age was 51.14 (range = 30-63) years. Nine patients (27%) asked for nipple-areola reconstruction. Three patients had major complications (9%), including infection, partial flap ischemia, and liponecrotic pseudocysts. Eight patients required revision. Seroma was the most common problem observed at the donor site. CONCLUSION The latissimus dorsi flap provides adequate soft tissue with a reliable blood supply for the enhancement of missing tissue after mastectomy. It is a safe method for breast reconstruction and an excellent alternative flap for patients at high risk for abdominal flap complications.
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